Serious case review published

17 February 2015

A serious case review (SCR) has been published today (17 February 2015) which concerns the death in 2013 of an elderly man living at a Jersey Care Home.

The SCR has been published by the Independent Chair of the Safeguarding Partnership Board, Glenys Johnston OBE, together with a shorter report which summarises the key learning points from the case.

Assessment of mental capacity

The circumstances outlined in the report are that, a man in his late 80s, died in residential care in June 2013. He had been receiving antibiotics for bronchopneumonia which were sometimes given to him in food without his knowledge. Although this is not an unusual practice, concerns were subsequently raised by Health and Social Services Adult Safeguarding team about whether the man’s mental capacity had been properly assessed to see whether he could make the decision himself whether or not to take medication. Following this intervention, The man's medication was temporarily stopped. He died five days later from bronchopneumonia.

The main themes of the report concern the administration of medication, whether an adequate assessment of his mental capacity was made and the intervention by Adult Safeguarding at Health and Services.

Mrs Johnston said “This case involved a complex man, who did not like doctors and never took medication. Consequently, his care gave rise to considerable challenges for those looking after him. The findings do make it clear that staff at the residential care home and other professionals provided good care to the man. However, the review also indicates a lack of clear strategy for making decisions about this gentleman’s care and the assessment of his mental capacity.

“The purpose of an SCR is not to apportion blame but to ensure that lessons are learned and we improved the way we work to safeguard adults. A number of improvements have already been made in the light of this report, including improved training, the development of multi-agency adult safeguarding procedures and a new Safeguarding Adults Team with increased experience.”
 

Recommendations for change

Mrs Johnston said that report identified a number of key areas in which practice and procedure should be improved. The recommendations for change made in the report include:

• the provision of full information by the General Hospital to residential care homes on discharge, so that this can be included in a care plan.
• the provision of care managers for people with complex needs, to co-ordinate the work of involved professionals.
• updated adult safeguarding policies and procedures as well as training about assessing capacity and making best interest decisions.
• ensure that all key professionals, including GPs, are included in multi-agency decision making.

“The Safeguarding Adults Partnership Board and its member agencies will do everything they can to support services in implementing change and providing training to assist staff and ensure best practice guidance is followed,” said Mrs Johnston.

SCRs into cases are commissioned by the Safeguarding Adults Partnership Board where abuse or neglect of an adult is known or suspected and the individual has died or been seriously harmed and there is serious cause for concern about the way in which agencies have worked together to safeguard an individual. They are intended to establish whether lessons can be learned, identify those lessons and to improve inter-agency working and promote the welfare and safeguarding of adults.

Neither the man nor the care home at which he was living are identified in the S​CR. The man's family have been involved in the SCR process and have agreed to the publication of the report.